Name and Address of Nearest Relative Not in Household, that we may contact

Telephone

Co-Applicant Name

Date of Birth

Driver’s License No.

State License Issued In

Social Security Number

Employer

Position

Years There

Business Phone

Nearest Relative Not in Household

Relationship

Address

Please Select the Accounts you would like to open

Checking Accounts: Savings Accounts:

Community Points Checking

Regular Savings

Commercial Checking

ATM Savings

Small Business Checking

Christmas Club

Vacation Club

Certificate of Deposit

Individual Retirement Account

Interest Bearing Checking Accounts:

Reward Checking

Now Account

Money Market Account

Customer Information Policy

In accordance with Section 326 of the USA Patriot Act signed October 26, 2001, Community is required to obtain a copy of documents used in identifying our new account customers and in identifying signatory individuals added to existing or new accounts. In some cases, identification will be requested for those individuals banking with the bank prior to the effective date of the customer identification requirements because original documentation was not obtained with the opening of the account, or the bank is unable to form a reasonable belief that it knows the identity of the existing customer. In all cases protection of our customer’s identity and confidentiality is the Bank’s pledge to you.

Applicants Signature

By completing the above, I am providing information for the purpose of obtaining an account and I authorize Community Bank to obtain information concerning any of the statements I have made. I also authorize Community Bank to make inquiries they feel are necessary to determine my credit worthiness including, but not limited to, obtaining credit reports from credit reporting agencies and other credit information from other sources.

I understand that this application is subject to Community Bank approval. Fax completed application to (985) 537-6414; upon approval, you will be contacted to sign documents for the new account. Or you can deliver the completed application in person to any Community Bank office.